Covered California is where Californians can shop for and compare quality health plans among a variety of brand-name insurance companies. You may even get help paying for it. This guide will help you better understand your coverage options so you can enroll in the health plan that best fits your needs.

Based on your annual household income, you may qualify for what’s called an Advanced Premium Tax Credit (APTC) to help reduce your monthly premiums. Or you may qualify for low or no-cost coverage through Medi-Cal.

Coverage Year 2018

Maximum Annual Household Income to Qualify for Financial Help

FAMILY SIZE

MEDI-CAL

COVERED CALIFORNIA

1

$16,643

$48,240

2

$22,412

$64,960

3

$28,180

$81,680

4

$33,948

$98,400

5

$39,717

$115,120

6

$45,485

$131,840

You may be eligible
for low or no-cost
Medi-Cal.

You may be eligible for
financial help through
Covered California.

Step 2

Explore your coverage options

Covered California offers four levels of coverage: Bronze, Silver, Gold and Platinum. Insurance companies pay a portion of covered services, and the benefits offered within each level are the same no matter which insurance company you choose.
• Choose Platinum or Gold and you’ll pay a higher monthly premium, but you’ll pay less for medical services.
• Choose Silver or Bronze and you’ll pay a lower monthly premium, but you’ll pay more for medical services.
• A minimum coverage plan is available to those under 30 or those 30 and over who have received a hardship exemption from U.S. Department of Health and Human Services.

Standard coverage benefits by level

KEY BENEFITS

BRONZE
Covers 60% of average annual cost

SILVER
Covers 70% of average annual cost

GOLD
Covers 80% of average annual cost

PLATINUM
Covers 90% of average annual cost

Individual/Family Deductible

$6,300/$12,600

$2,200/$4,400**

No deductible

No deductible

Annual Preventive Care Visit

No cost

No cost

No cost

No cost

Primary Care Visit Copay

$75*

$30†

$25

$15

Urgent Care Visit Copay

$75*

$30†

$25

$15

Emergency Room Copay

Full cost up to deductible

$350†

$325

$150

Generic Medication Copay

Full cost up to $500 deductible

$15†

$15

$5

Annual Out-of-Pocket Maximum for One

$7,000

$5,850

$6,000

$3,350

Annual Out-of-Pocket Maximum for Family**

$14,000

$11,700

$12,000

$6,700

Chart does not include all medical copays and coinsurance rates.
* For Bronze Plans, the deductible is waived for the first three primary care or urgent care visits. Additional visits are charged at full cost until deductible is met.
** Silver is the only level where your deductible and other costs may be lower based on your household income.
† These benefits are not subject to any deductible.

Step 3

What you need to enroll

The following is needed for every household member who is applying for coverage:

•

Proof of current household income*

•

Birth date

•

California ID or driver’s license for adults

•

Home ZIP Code

•

Social Security number or Individual Taxpayer Identification number, if you have one

The Affordable Care Act (ACA)
As part of the ACA, Covered California is a program where most legal residents of California and their families can compare quality health plans and choose the one that works best for their health needs and budget. The law requires that:

• Young adults can be covered under their parents’ plan until the age of 26.

• All plans include free preventive care.

Am I required to have health insurance?

Most people are required by law to have health insurance or pay a tax penalty. In 2018, the penalty is $695/adult, $347.50/child under 18 (up to $2,085/family) or 2.5% of your annual household income over your tax filing threshold, whichever is higher.

The ABCs of HMOs, PPOs and EPOs
Most insurance companies offer three types of plans:

HMOs
Health Maintenance Organizations only cover medical services inside the plan’s network. HMOs often require members to get a referral from their primary care doctor to see a specialist.

PPOs
Preferred Provider Organizations pay for medical services both inside and outside the plan’s network, but members pay a higher amount of the cost for out-of-network care. No referral is required to see a specialist.

EPOs
Exclusive Provider Organizations generally don’t cover care outside the plan’s network, but members may not need a referral to see an in-network specialist.

It’s important to note that not all HMOs, PPOs and EPOs are the same. Before choosing a plan, your LK Health Enrollment Counselor can obtain details for you such as what doctors and hospitals are covered and what it will cost to see a doctor out-of-network.

* Proof of current income of all members in the tax household, such as a recent tax return, W-2, or pay stub. A dependent’s income should only be included if their income level requires them to file a tax return. A household is defined as the person who files taxes as the primary tax filer and all the dependents claimed on that person’s taxes. If you don’t file taxes, you can still qualify for free or low-cost insurance through Medi-Cal.
** You can apply for your child even if you are not eligible. Households that include members who are not lawfully present can also apply.